Contents

Introduction

This Advance Report is a synthesis of findings presented at the 51st biannual meeting of the Community Epidemiology Work Group (CEWG) held in San Diego, California, on December 11-14, 2001. Sponsored by the National Institutes of Health, National Institute on Drug Abuse (NIDA), the CEWG is a network of epidemiologists and researchers in the United States that meets biannually to review current and emerging substance abuse problems. The members present drug abuse indicator data, survey findings, and other quantitative information compiled from local, city, State, and Federal sources. To assess drug abuse patterns and trends, data from a variety of health and other drug abuse indicator sources are accessed and analyzed. Sources include public health agencies, medical and treatment facilities, medical examiners' and coroners' offices, criminal justice and correctional offices, law enforcement agencies, poison control centers, and sources unique to local areas.

National data are used to enhance what is presented by CEWG members. Large-scale Federal databases used in analyses include the Treatment Episode Data Set (TEDS), and the Drug Abuse Warning Network (DAWN) data on emergency department (ED) drug-related mentions and medical examiner (ME) drug-related deaths maintained by the Substance Abuse and Mental Health Services Administration (SAMHSA); the Arrestee Drug Abuse Monitoring (ADAM) program funded by the National Institute of Justice (NIJ); the Domestic Monitor Program (DMP), the National Forensic Laboratory Information System (NFLIS), and other information on drug seizures, price, and purity from the Drug Enforcement Administration (DEA); and the Uniform Crime Reports maintained by the Federal Bureau of Investigation (FBI). These data are enhanced with qualitative information obtained from ethnographic research, focus groups, and other community-based sources.

The CEWG areas include:

Atlanta

Los Angeles

Phoenix

Baltimore

Miami

St. Louis

Boston

Minneapolis/St. Paul

San Diego

Chicago

Newark

San Francisco

Denver

New Orleans

Seattle

Detroit

New York

Texas*

Honolulu

Philadelphia

Washington, D.C.

* Includes Dallas and other areas in Texas

Information reported at each CEWG meeting is distributed to drug abuse prevention and treatment agencies, public health officials, researchers, and policymakers. The information is intended to alert authorities at the local, State, regional, and national levels, and the general public, to the current conditions and potential problems so that appropriate and timely action can be taken. Researchers also use this information to develop research hypotheses that might explain social, behavioral, and biological issues related to drug abuse.

In addition to ongoing assessment of drug patterns and trends in the United States, the CEWG provides a forum for the discussion of drug patterns and trends in other areas and regions of the world. This meeting included presentations on drug abuse surveillance and other research in Canada and Mexico. Mexican representatives provided an update on treatment data and findings from an ethnographic study focused on heroin. A representative of the Centre for Addiction and Mental Health in Toronto, Ontario, presented highlights from the 2001 Ontario Student Drug Use Survey. These data on senior students were compared with 2000 data reported by the Monitoring the Future Study, conducted by the Institute for Social Research, University of Michigan.

Michael Ann Haight, San Diego CEWG member, planned and organized a series of presentations and panels focused on issues and interventions in San Diego County, including the following: the Methamphetamine Vista Partners Project; the Drug Endangered Children's Project; Proposition 36 (The Substance Abuse and Crime Prevention Act) plans and programs; Matrix, a Multi-Site Treatment Program for Methamphetamine; a dialogue with methamphetamine abuse clients; and the Border Collaborative Project.

In addition, a DAWN Data Workshop was conducted and an official of DEA described the data sources used by the DEA to track 3,4-methylenedioxymethamphetamine (MDMA) seizures and determine the quality of drugs.

Drug Abuse Highlights for the United States

Data from the 51st CEWG meeting portrayed both the similarities and the diversity of drug abuse patterns within and across CEWG areas, as well as changes in trends over time. The findings presented in this report are based primarily on comparisons of 1999 and 2000 data. In some instances, the findings are supplemented by data from earlier periods and data from the first half of 2001. The major findings are highlighted below.

COCAINE/CRACK Although still at high levels, cocaine/crack indicators decreased in 10 CEWG areas, remained stable or mixed in 9, and increased in 2 (Atlanta and Seattle). As crack use has decreased, powder cocaine has become more available in some CEWG areas including Denver, Miami/South Florida, Phoenix, the Texas border, and Washington, D.C.

HEROIN Heroin use indicators increased in 15 CEWG areas, remained stable in 2, and decreased in 4. Decreases were reported in Honolulu, Los Angeles, San Francisco, and Seattle, areas where Mexican black tar is the primary type of heroin available. Areas located on the East Coast, including Boston, New York, Newark, and Philadelphia, report that heroin is relatively cheap, widely available, and of high purity.

OTHER OPIATES Indicators of the illicit use of prescription semisynthetic narcotic drugs, such as oxycodone and hydrocodone, increased in the 14 CEWG areas that reported on these drugs. Oxycodone ED mentions in 2000 were highest in Philadelphia (195), Boston (122), and Seattle (94). It was also reported that oxycodone could be purchased near methadone clinics in Washington, D.C. In Texas, there were 52 deaths involving hydrocodone and 8 involving oxycodone in 2000.

MARIJUANA Marijuana use indicators increased in 12 CEWG areas, remained stable or mixed in 8, and decreased in 1 (Atlanta). Although marijuana ED mentions, arrests, and treatment admissions have been increasing, there is reportedly less stigma associated with the use of this drug than in prior years, and it is widely available in all CEWG and surrounding areas. In 2000, high proportions of clients entering drug treatment programs in New Orleans (29.2 percent), St. Louis (27.5 percent), New York (25.4 percent), Atlanta (21.1 percent), and Denver (16.5 percent), reported marijuana as their primary drug of abuse. In the first 6 months of 2001, Minneapolis/St. Paul reported that 22.9 percent of treatment admissions were for primary marijuana abuse.

METHAMPHETAMINE Methamphetamine use indicators increased in six (Denver, Honolulu, Los Angeles, Phoenix, San Diego, and Seattle) of the seven CEWG areas that typically have relatively high rates of ED methamphetamine mentions and/or high percentages of primary methamphetamine treatment admissions. The seventh, San Francisco, was the only area reporting a decrease in methamphetamine indicators in 2000-2001. Increases in methamphetamine indicators were also reported in Atlanta, Minneapolis/St. Paul, St. Louis, and cities in Texas. Chicago, Detroit, New York, Philadelphia, and Washington, D.C., reported increases in methamphetamine availability and use, but still at low levels.

CLUB DRUGS MDMA indicators increased in 19 CEWG areas and remained stable (at low levels) in 2 -- New Orleans and Newark. Although the numbers of MDMA ED mentions are still low compared with those for other drugs, they have been increasing dramatically in most CEWG areas. In recent years, according to the DEA, clandestine laboratories in the Netherlands and Belgium have produced 80 percent of the MDMA consumed worldwide. There have been reports of attempts to establish clandestine labs capable of producing MDMA in CEWG sites, including Minneapolis, San Diego, and areas of Michigan and South Florida. Pills sold as ecstasy were found to contain mixtures of a variety of chemicals/substances, making them more dangerous to use; some do not contain any of the precursors needed to produce MDMA.

PCP PCP indicators were reported in 14 CEWG areas. In 2000, PCP ED mentions were especially high in Chicago (1,003) and relatively high in Washington, D.C. (317), Dallas (120), and St. Louis (98). Los Angeles reported 51 PCP-involved deaths in 2000. Only a small number of ADAM arrestees tested positive for PCP in any CEWG site included in ADAM.

Cocaine/Crack

In most CEWG areas, cocaine/crack indicators have been stabilizing and/or trending down for some time. Between 1999 and 2000, cocaine/crack indicators decreased in 10 areas, were stable or mixed in 9, and increased in only 2. Rates of DAWN cocaine ED mentions per 100,000 population tended to be much higher than the rates for other drugs. ADAM data continue to show that high percentages of arrestees test positive for cocaine, with females more likely than males to test positive. In 2001, large proportions of clients entering drug abuse treatment programs were primary crack users.

Crack indicators continue to remain at high levels in most CEWG areas despite the fact that new drugs have emerged in recent years, other drugs have become more available and less expensive, and crack has a bad reputation on the street. As stated in the Washington, D.C., report, Crack is viewed in a negative light and is not considered popular among new drug abusers. Crack is associated with violent and desperate behavior in disadvantaged communities in D.C. In other D.C. communities, crack is also eschewed by middle-class users of illicit substances.

Increases from 1999 to 2000-01 in cocaine/crack indicators were reported in two areas:

Atlanta After a steady decline in cocaine indicators, increases were reported in 2000. The rate of ED mentions increased from 189 in 1999 to 221 in 2000. In 2000, 48.5 percent of male and 57.6 percent of female arrestees tested positive for cocaine. Almost one-half (48.6 percent) of treatment admissions were for cocaine/crack abuse.

Seattle Indicators of cocaine use have shown an increase to higher historical levels after several years of decline. The rate of cocaine ED mentions increased from 130 in 1999 to 169 in 2000. In the past 3 years primary cocaine admissions to treatment represented 12 percent of all admissions.

The following excerpts are from CEWG areas reporting increased use of powder cocaine:

Denver Cocaine injecting declined from 1995 (12.4 percent) through 1998 (10.6 percent), but increased slightly to 13.7 percent in the first half of 2001. Smoking percentages, though level at 67.2 percent in 1995 and 1996, have since declined steadily to a low of 56.7 percent in the first half of 2001. Conversely, inhalation has been steadily increasing from 17.6 percent in 1995 to 26.3 percent in the first half of 2001. This is probably due to the increased availability of cocaine hydrochloride (HCl).

Miami/South Florida Crack cocaine was specifically mentioned in 31 percent of the cases in the first half of 2001, down slightly from 36 percent during 2000. There were 4,383 cocaine and crack ED mentions reported in the year 2000 for Miami-Dade County by the DAWN system. Of this number 2,645 (60.3 percent) were for powder cocaine and 1,712 (39.1 percent) were for crack.

Phoenix Cocaine hydrochloride is consistently available throughout the Phoenix, Tucson, and Nogales areas of Arizona, according to the DEA.

Washington, D.C. Especially in the northwest quadrant of the city, ethnographic respondents report that cocaine HCl is used by members of Washington's professional class in nightclubs and dance party settings within straight and gay scenes in certain affluent neighborhoods in D.C..

The rates per 100,000 population for cocaine/crack ED mentions in 2000 are depicted on the map in exhibit 1 for each CEWG area. As shown, rates of cocaine/crack ED mentions exceeded 200 per 100,000 population in 5 CEWG areas: Chicago (246), Miami (225), Atlanta (221), Philadelphia (216), and Baltimore (208).

As shown in exhibit 2, in five eastern CEWG areas, cocaine/crack ED mentions trended downward from 1997 to 2000, although the numbers continued to be high, especially in New York City and Philadelphia. In Boston, Dallas, Denver, Detroit, San Diego, and San Francisco, ED cocaine/crack levels remained relatively stable in 2000.

International Highlights

Canada

Edmonton Report. This report focused on drug abuse patterns and trends in Edmonton, Alberta, 1 of the 14 sites that participate in the Canadian Community Epidemiology Network on Drug Use. Data are accessed from a variety of sources including treatment providers, law enforcement agencies, health agencies, medical examiners, surveys, and ethnographic studies. The most frequently mentioned drugs used by injectors seeking treatment included cocaine (64.3 percent), heroin/opiates (21.7 percent), pentazocine (Talwin) (8.6 percent), and amphetamines (4.2 percent). A multi-centre survey of 299 street youth was conducted to learn more about drug use patterns. Approximately 71 percent of street youth reportedly used cannabis in the 3-month period prior to the survey. More than one-half (56 percent) reported binge drinking in the previous 3 months.

2001 Ontario Student Drug Use Survey. Highlights were presented from the 2001 Ontario Student Drug Use Survey, which is a province-wide survey conducted every 2 years by the Centre for Addiction and Mental Health. The current survey includes samples from grades 7 through 13. (Only grades 7, 9, 11, and 13 were surveyed prior to 1999.) The survey included 41 boards, 106 schools, and 4,211 students. A two-stage probability sampling procedure was used, with oversampling of Northern Ontario students. A comparison of the 1999 and 2001 survey data showed declines in cigarette smoking (29.2 to 23.6 percent), use of solvents (7.1 to 5.7 percent), and LSD use (6.8 to 4.5 percent). Comparison of the survey data in 2001 with that from 1993 shows increases in cannabis use (28.6 vs. 12.7 percent), as well as MDMA (6.0 vs. 0.6 percent), PCP (2.4 vs. 0.6 percent), and hallucinogens (10.3 vs. 3.1 percent), but a decline in cocaine use (1.5 vs. 3.8 percent). Rates of drug use among Ontario's 13th-graders were also compared to those for 12th-graders in the United States, as reported in the Monitoring the Future study, conducted by the Institute for Social Research at the University of Michigan. Estimates of drug use for Ontario students were within sampling error of U.S. estimates for cannabis, cocaine, LSD, and MDMA. Ontario students were more likely to report use of hallucinogens such as mescaline and psilocybin. Only small percentages in both studies reported past-12-month use of heroin, GHB, or Rohypnol.

Mexico

Mexico's Epidemiologic Surveillance System of Addictions, a network of institutions specializing in addiction research, operates in 25 Mexican cities, half of which are located along the U.S.-Mexico border. The primary sources of data are governmental and nongovernmental treatment centers reporting on clients in treatment.

During the first half of 2001, data were gathered from 5,905 patients in government treatment centers (GTCs) and 5,536 patients in nongovernment treatment centers (NGCs). In both types of facilities, cocaine was the drug most likely to be used currently (42.6 percent of GTC and 30.5 percent of NGC patients). Marijuana was the second most frequently reported current drug of abuse among GTC patients (20.0 percent) and ranked third among NGC patients (14.9 percent). Heroin was reported as a current drug of abuse by 17.5 percent of NGC patients but only 2.2 percent of GTC patients. Inhalants accounted for 11.7 percent of current drug reports among NGC patients. Approximately 90 percent of patients in both types of facilities were male and the majority used more than one drug.

MDMA Trafficking in the United States

The sources used by DEA to assess the trafficking of MDMA in the United States were reviewed by an official of DEA's Office of Diversion Control. These included the System to Retrieve Information on Drug Evidence (STRIDE); United States Customs Service reports; NFLIS; and the DEA Source Determination Program.

DEA drug testing laboratories are located in seven CEWG areas: Miami, New York City, Washington, D.C., Chicago, Dallas, San Francisco, and San Diego. In addition, a special testing and research lab is located in Chantilly, Virginia. Through the first 11 months of 2001, approximately 2,700 MDMA exhibits have been analyzed by STRIDE.

Based on STRIDE data, Florida, New York, and California are the highest MDMA trafficking areas in the United States. Other States that have significant MDMA trafficking include New Jersey, Illinois, Georgia, Texas, Massachusetts, Virginia, and Washington, D.C. The United States Customs Service has been seizing more MDMA tablets each year: 400,000 in 1997, 750,000 in 1998, 3,500,000 in 1999, and 9,300,000 in 2000. At NFLIS, 5,882 MDMA exhibits were encountered in 2000 and 3,610 through November 2001.

The DEA Source Determination Program analysis of MDMA samples in 2000 showed that 12 percent of the samples contained amphetamine or methamphetamine, but not MDMA; 5 percent contained no controlled substances; and 3 percent were determined to be other substances, but were sold as ecstasy.

In 2000, 3,346,071 MDMA tablets were analyzed in DEA labs. The average dose was 87 milligrams. Tablets believed to be MDMA were often found to contain other substances including caffeine, ephedrine, dextromethorphan, and diphenhydramine (an OTC antihistamine).

In 2000, 63 percent of MDMA tablets were smuggled into the United States by airline, 27 percent by express mail, and 10 percent by shipping. The departure points for MDMA smuggled into the country were the Netherlands (77 percent), France (9 percent), Belgium (8 percent), Germany (3 percent), and Spain (3 percent).